SUS PBR REFERENCE MANUAL

 
 
SUS PBR REFERENCE MANUAL
SUS PbR
Reference Manual
SUS PBR REFERENCE MANUAL
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SUS PbR Reference Manual v1.3




Contents
Introduction                                                                                                     9

  This Document                                                                                                   9
  Secondary Uses Service (SUS)                                                                                    9
  Payment By Results (PbR)                                                                                        9
     Coverage                                                                                                     9
     Coding and Submitting Patient Data                                                                          10
     Pricing                                                                                                     10
     Currency                                                                                                    10
     Impact of PbR                                                                                               10
     SUS Payment by Results (PbR)                                                                                11
     SUS Extract Mart (SEM)                                                                                      11

Submitting CDS Data                                                                                              13

  Introduction                                                                                                   13
  Commissioning Data Sets (CDS)                                                                                  13
     CDS Types                                                                                                   13
     Submission Timetable                                                                                        13

  Reconciliation and Post-reconciliation points                                                                  14
     Reconciliation                                                                                              14
     Post-reconciliation                                                                                         14

  Flowing Data to Support Locally Priced Activity                                                                14

Spell Construction                                                                                               17

  Introduction                                                                                                   17
  Spells                                                                                                         17
  Slab Logic                                                                                                     17
  Slabs                                                                                                          17
     Slab 0 - Day Case                                                                                           17
     Slab 1 - NHS Number (Ordinary Admission)                                                                    17
     Slab 2: Provider Spell Number, DoB & Person Gender Current (Ordinary Admission)                             18
     Slab 3: Local Patient Identifier & DoB (no longer used)                                                     18
     Slab 4: DoB, Person Gender Current, Validated Postcode (no longer used)                                     18
     Slab 5: Confidential Patient                                                                                18
     Slab 6: Same Day Admissions                                                                                 18
     Slab 7: Regular Admissions                                                                                  18

  Numbering and Ordering                                                                                         19
  Application of Slabs 0, 7 and 5 – Single Episode Spells                                                        19

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    Application of Slab 6 - Same Day Admissions                                                                         19
      Example Scenarios                                                                                                 19

    Application of Slabs 1, 2 and Zero LoS Rules                                                                        20
    Global Validation Rules                                                                                             24
      Overlapping Episodes                                                                                              24
      Missing Episodes                                                                                                  24

Validation, Processing and Data Quality                                                                                 27

    Introduction                                                                                                        27
      Applicable Patient Care Settings                                                                                  27

    Validation                                                                                                          27
      XML Schema Validation                                                                                             27
      SUS Business Rules                                                                                                27
      SUS Processing                                                                                                    27
      HRG Validation                                                                                                    28

    Derivations                                                                                                         28
      Types of Derivations                                                                                              28
      Counts                                                                                                            28

    Data Quality                                                                                                        29
      Data Quality Flags                                                                                                29
      Data Cleansing                                                                                                    29
      Critical Care                                                                                                     29
      HRG Grouping                                                                                                      30
      SUS Data Quality Dashboards                                                                                       30
      Tracker                                                                                                           30

HRG Grouping                                                                                                            31

    Introduction                                                                                                        31
      HRGs                                                                                                              31
      HRG Design                                                                                                        31
      The Casemix ‘Local’ Grouper                                                                                       31

    Grouper Processing                                                                                                  31
      Simplified Grouping Diagram                                                                                       31
      Validation                                                                                                        32
      Radiology Pre-processing                                                                                          32
      Pre-processing:                                                                                                   32
      Unbundled Activity:                                                                                               32
      Grouping                                                                                                          32
      Assign Flags (BPT, SSC, PBC)                                                                                      32

    Unbundled HRGs                                                                                                      32

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  ‘Differences’ between the SUS Grouper and Local Grouper                                                        33

Critical Care                                                                                                    35

  Introduction                                                                                                   35
  PbR Critical Care Extract                                                                                      35
     CC Types and CC Periods                                                                                     35
     Derived PbR Data Items                                                                                      36
     Linkage to Episode/Spell Extracts                                                                           36

  Validation of Submitted Data                                                                                   37
     SUS Critical Care Processing Summary                                                                        37

  Counting and Allocating Critical Care Days                                                                     38
  Grouping                                                                                                       40
     Grouping Logic                                                                                              40
     NCC and PCC Daily Records                                                                                   40
     ACC ‘Per Diem’ Multiplier                                                                                   40
     Overlapping in Grouping                                                                                     40

  PbR Final Adjusted Length of Stay                                                                              41
     Calculation                                                                                                 41
     Zero Floor Limit                                                                                            41
     PbR Adjustment                                                                                              41
     Overlapping Critical Care Periods                                                                           41

  PbR Critical Care Indicators                                                                                   42
     Further Information:                                                                                        46

Best Practice                                                                                                    47

  Introduction                                                                                                   47
  Best Practice Tariffs                                                                                          47
     Best Practice Tariffs in Extracts                                                                           47
     Best Practice Tariff Indicator Actions:                                                                     47
     Ineligible Combinations                                                                                     48

  Cataracts Best Practice Pathway                                                                                48
     BP - Cataracts Extract                                                                                      49

  Global BPT Processing                                                                                          49
     Length of Stay Checks                                                                                       49
     Age Checks                                                                                                  49
     Short Stay Emergency                                                                                        49
     Short Stay Emergency Tariff                                                                                 50
     APC Mandatory Tariff                                                                                        50
     BPT and SSC Flags                                                                                           50
     Count Data Items                                                                                            50

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SUS PbR Reference Manual v1.3

      Output Limits                                                                                                     51

Readmissions                                                                                                            53

    Introduction                                                                                                        53
    Defining Readmissions                                                                                               53
      NHS Number                                                                                                        53

    Constructing Readmission Pathways                                                                                   54
      ‘Frozen’ Data                                                                                                     54
      RAP Identifier and RAP Sequence Number                                                                            55
      PARENT-CHILD Relationships                                                                                        55
      Spell Ordering Within Pathways                                                                                    56
      Multiple Same Day Admissions                                                                                      56

    Policy Exclusions: CHILD Spell                                                                                      56
      Patient Age                                                                                                       57
      Core HRG                                                                                                          57
      Unbundled HRG                                                                                                     57
      Primary Diagnosis                                                                                                 57
      Country Code                                                                                                      57

    Policy Exclusions: PARENT Spell                                                                                     58
      Spell in PbR / Not in PbR (PbR Qualified Indicator)                                                               58
      Core HRG                                                                                                          58
      Primary Diagnosis                                                                                                 58
      Spell Unbundled HRG                                                                                               58
      Discharge Method                                                                                                  58
      Main Speciality Code (MSC)                                                                                        59
      Country Code                                                                                                      59
      Admission Subtype                                                                                                 59
      Treatment Function Code (TFC)                                                                                     59

    Non SUS-Applied Policy Exclusions                                                                                   59
    Identifying Non-Payment Activity                                                                                    59
      RAP DH Tariff Adjustment Child                                                                                    60
      RAP DH Tariff Adjustment Parent                                                                                   60
      Identifying Transfers                                                                                             60
      RAP Spell Transfer Out                                                                                            61
      RAP Spell Transfer In                                                                                             61
      Rules and Flags                                                                                                   61
      Example:                                                                                                          61

    Readmissions in Extracts                                                                                            62
      Access                                                                                                            62
      NHS Number                                                                                                        62

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SUS PbR Reference Manual v1.3

     Available Data Items                                                                                        62
     APC Spells Extract                                                                                          63

Reconciling SUS PbR with Local Systems                                                                           65

  Introduction                                                                                                   65
     Methodology                                                                                                 65

  Causes of Differences                                                                                          66
  Consistent Data                                                                                                66
  Differences in Output from PbR and SEM Data Marts                                                              67
  SUS PbR – Processing Issues                                                                                    68
     Net Change                                                                                                  68

  Data Consistency                                                                                               69
     Identifying Organisations and Reasons for Access                                                            69
     Reasons for Access                                                                                          69

  Spell Construction                                                                                             69
     Spell Construction Anomalies                                                                                70

  Incorrect Data Preparation for Local HRG Grouping                                                              71
  Identification of Activity to Tariff                                                                           71
  Provider Requested Exclusions                                                                                  71

Glossary                                                                                                         73




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Introduction                                          Secondary Uses Service (SUS)
                                                      The Secondary Uses Service (SUS) is the
This Document                                         central repository which supports the flow of
                                                      Commissioning Data Sets (CDS) between
The SUS PbR Reference Manual has                      providers and commissioners.
been designed to meet user needs as
expressed in the SUS PbR User
Documentation Survey conducted in
                                                      Payment By Results (PbR)
autumn 2013.                                          Payment by Results (PbR) provides a
                                                      transparent, rules-based system for paying
The purpose of this document is to                    NHS funded care in England.
consolidate existing information and
introduce guidance in new or previously               It rewards efficiency, supports patient
unexplored areas. It should therefore be              choice and diversity and encourages
considered as a ‘living’ document which can           activity for sustainable waiting time
be updated in response to further user                reductions.
feedback. New chapters can be produced
and existing chapters enhanced based on               Payment is linked to activity and adjusted
user requests.                                        for casemix. This ensures a fair and
The development of new user support                   consistent basis for hospital funding rather
materials will also be used as a basis for            than being reliant principally on historic
how we will support users during and after            budgets and the negotiating skills of
transition to the National Tariff System              individual managers.
(NTS) which will replace the existing SUS
service in the long term.                             PbR is the payment system in England
                                                      under which commissioners pay healthcare
SUS users are therefore encouraged to                 providers for each patient seen or treated,
provide feedback and suggestions for areas            taking into account the complexity of the
of improvement in existing guidance and               patient’s healthcare needs. The two
new requirements for support materials.               fundamental features of PbR are nationally
These requests will be addressed by                   determined currencies and tariffs.
resources dedicated to improving support              Currencies are the unit of healthcare for
for users across the SUS and future                   which a payment is made, and can take a
replacement and NTS systems, in terms of              number of forms covering different time
PbR, SUS system usage, access, analysis               periods from an outpatient attendance or a
and training.                                         stay in hospital, to a year of care for a long
                                                      term conditions. Tariffs are the set prices
To get in touch and ensure your query is              paid for each currency.
appropriately addressed, please contact
HSCIC enquiries and include ‘SUS User
Documentation Feedback' in your email                 Coverage
subject line.                                         PbR currently covers the majority of acute
                                                      healthcare in hospitals, with national tariffs
enquiries@hscic.gov.uk
                                                      for admitted patient care, outpatient
                                                      attendances and accident and emergency.
                                                      This activity is submitted using
                                                      Commissioning Data Sets (CDS). Current
                                                      policy intends that the scope of PbR and
                                                      national tariff will expand in future by
                                                      introducing currencies and tariffs for mental
                                                      health, community and other services.

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SUS PbR Reference Manual v1.3


Coding and Submitting Patient Data                         services, or to support particular policy
When a patient is discharged, a clinical                   goals.
coder working in the hospital translates
their care into codes. Two classification                  Currency
systems, ICD-10 for diagnoses and OPCS-                    The currency for admitted patient care,
4 for procedures (interventions) are used.                 outpatients and A&E is Healthcare
When a patient attends an outpatient clinic,               Resource Groups (HRG). HRGs are
their Treatment Function Code (TFC) is                     clinically meaningful groupings of
similarly recorded.                                        diagnoses and interventions that consume
                                                           similar levels of NHS resources. Grouping
For some outpatients it is appropriate to                  the extensive and growing number of
record procedures performed as these will                  clinical codes into HRGs allows tariffs to be
allocate an HRG that is priced under                       set at a sensible and workable level. For
different rules to standard OP attendances.                APC each HRG covers a spell of care, from
This information, together with other                      admission to discharge.
information about the patient such as age
and length of stay, is sent to SUS via CDS.
Extract reports produced by SUS allow                      Impact of PbR
commissioners to pay providers for the                     Before PbR, it was common practice for
work they have done or to adjust any                       commissioners to have block contracts with
regular monthly payments for actual activity               hospitals where the amount of money
undertaken.                                                received by the hospital was fixed
                                                           irrespective of the number of patients
Pricing                                                    treated. PbR was introduced to:
Tariff prices have traditionally been based
                                                                    Support patient choice by
on the average cost of services reported by
                                                                     allowing the money to follow the
NHS providers in the mandatory annual
                                                                     patient to different types of
reference costs collection. In practice,
                                                                     provider.
various adjustments are made to the
average of reference costs, so final tariff
                                                                    Reward efficiency and quality by
prices may not reflect published national
                                                                     allowing providers to retain the
averages. The reference costs from which
                                                                     difference if they could provide
the tariff is produced are three years in
                                                                     the required standard of care at a
arrears. Therefore an uplift is applied which
                                                                     lower cost than the national price.
reflects pay and price pressures in the
NHS, and includes an efficiency
requirement. The introduction of best                               Reduce waiting times by paying
practice tariffs in 2010/11 began to                                 providers for the volume of work
introduce the policy concept that tariffs                            done.
should be determined by best clinical
practice rather than average cost.                                  Re-focus discussions between
                                                                     commissioner and provider away
The tariff received by the provider is                               from price and towards quality
multiplied by a nationally determined                                and innovation.
market forces factor (MFF). This is unique
to each provider and reflects the fact that it             PbR was introduced to support healthcare
is more expensive to provide services in                   policy and the strategic aims of the NHS.
some parts of the country than in others.                  As these have changed and developed
There may also be other adjustments to the                 over time, so has PbR. The tariff is now
tariff for long or short stays, for specialised            seen increasingly as a vital means of
                                                           supporting quality outcomes for patients

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and delivering additional efficiency in the
NHS.

PbR is not unique to England. Many other
countries in Europe, North America and
Australasia operate similar payment
systems.

SUS Payment by Results (PbR)
SUS PbR is collection of rules, processes
and dedicated data marts that support
implementation of PbR policy. Derivations,
tariffs and business rules agreed with NHS
England and Monitor provide a common
and consistent mechanism to support
reconciliation of activity and payment
between providers and commissioners.
SUS PbR produces managed versions of
the data, generated at specified cut off
points known as the Reconciliation and
Post-Reconciliation (final reconciliation)
points to produce static snapshots. It can
additionally provide a current view of the
data held within SUS. All of these are
available via the SUS PbR Online service.

SUS Extract Mart (SEM)
SEM returns the data submitted to SUS
with a limited number of additional
derivations. These derivations include the
core spell and episode HRG derived by
SUS PbR and the GP Practice and
organisation codes derived by the Personal
Demographic Service (PDS). As SEM is
updated by each subsequent version of
activity data submitted, it reflects the
position within SUS at the time the extract
is taken and thus provides a changing view
over time.

Data extracted from SEM will show the
same position to that extracted from the
PbR Current mart.




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SUS PbR Reference Manual v1.3




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Submitting CDS Data                                    according to the Commissioning Data Set
                                                       Mandated Data Flows guidelines
                                                       available on the Data Dictionary website.
Introduction
Data is submitted to SUS via                           Commissioning organisations need access
Commissioning Data Sets (CDS).                         to data to monitor Non-Contract Activity as
Comprehensive information on CDS                       part of the management of their NHS
standards can be found in the NHS Data                 service agreements, and to monitor in-year
                                                       referral requests to investigate the sources
Dictionary.
                                                       and reasons for Non-Contract Activity.
www.datadictionary.nhs.uk
                                                       The Department of Health requires
For further details about setting up CDS               accurate data for all patients admitted,
flows and more information about                       treated as out-patients or treated in
submission and use of SUS, please refer to             accident and emergency by health care
the SUS Essentials guide, which can be                 providers, including patients receiving
found on the SUS Guidance pages of the                 private treatment. The Commissioning Data
HSCIC website.                                         Sets also include NHS patients treated
                                                       electively in the independent sector and
www.hscic.gov.uk/susguidance
                                                       overseas.


Commissioning Data Sets                                CDS Types
(CDS)                                                  The Commissioning Data Sets are used for
The purpose of the Commissioning Data                  the submission of commissioning data to
Sets (CDS) is to enable conformant health              SUS and are designed to be capable of
activity information to be generated across            individually conveying many different
the country, independent of the                        structures encompassing:
organisation or system that maintains it.                            Admitted Patient Care
This enables health care professionals to                            Outpatient Attendances
measure and compare the delivery and                                 Accident and Emergency
quality of care provided and to support                               Attendances (Emergency
them in sharing information with other                                Medicine)
health professionals and organisations.                              Future Attendances
Commissioning Data Sets currently support                            Elective Admission List data
the following activities:
        Monitoring and managing NHS                   Submission Timetable
         Service Agreements                            Submission of data to SUS is managed via
        Developing commissioning plans                a submission timetable which is published
        Supporting the Payment by                     annually on the SUS PbR Guidance page.
         Results processes                             www.hscic.gov.uk/sus/pbrguidance
        Underpinning clinical governance
        Understanding the health needs of             This timetable defines the Inclusion Date
         the population                                (the deadline for data submissions for
        Reporting waiting time measurement            inclusion in SUS PbR Managed Service
                                                       Extracts) and Publication Date (the
Information on care provided for all patients          guaranteed SUS PbR publication date for
by health care providers (both NHS Trusts              Managed Service Extracts).
and Independent Sector Healthcare
Providers for NHS patients only) must be
submitted to the Secondary Uses Service

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SUS PbR Reference Manual v1.3



Reconciliation and Post-                                  Flowing Data to Support
reconciliation points                                     Locally Priced Activity
PbR operates a two phase reconciliation                   Introduction
process to arrive at a final agreed position              Providers and commissioners wishing
for each month's activity.                                to identify activity that may be subject to
Reconciliation                                            local pricing arrangements can do so
                                                          within normal CDS submissions.
Providers submit initial data to SUS related
to activity in a calendar month. At a                     Following agreement between providers
nationally determined deadline as                         and commissioners on rules by which
mentioned above, the inclusion date, a                    specified services are identified, the
snapshot of this data is taken and extracts               provider applies that agreed coding to
are produced for both providers and                       appropriate activity within a CDS
commissioners. The point at which this first              submission.
snapshot is taken is referred to as either the
                                                          This may involve the inclusion of items that
reconciliation (or flex) point.
                                                          do not flow in the CDS but which are
Post-reconciliation                                       routinely available in the provider’s source
Providers and commissioners agree                         systems, such as codes for wards or clinics
between themselves which payments are to                  in which commissioners may have agreed
be made by whom during the reconciliation                 for specialised activity or activity supporting
period. Providers are responsible for re-                 a particular local initiative to be carried out.
submitting data to SUS reflecting the                     This locally identified activity may or may
agreements made with the commissioners.                   not be subject to extra payment which could
At a second nationally determined inclusion               not otherwise be identified from data items
date, for that month, a second snapshot of                included in the standard CDS message.
the data is taken and again extracts are
produced for both commissioners and                       Example Scenario
providers. This second snapshot point is                  A provider may have a problem with ‘Did
referred to as either the post-reconciliation             Not Attends’ in a children’s ENT (Ear Nose
(or freeze) point                                         and Throat) service. In agreement with the
                                                          main commissioner, clinics are set up to run
                                                          out of hours in the early evening which
                                                          involves overtime payments to clinic staff.
                                                          The commissioner agrees to an additional
                                                          payment to meet these extra costs.
                                                          Without use of the Service Agreement
                                                          data items, these appointments would
                                                          appear alongside regular ENT attendances.
                                                          Using the Service Agreement Details the
                                                          provider can identify appropriate records by
                                                          populating the NHS Service Agreement
                                                          Line Number data item with an agreed
                                                          code that identifies the extra clinics.
                                                          Alternatively, Provider Reference Number
                                                          could be populated with the agreed code.
                                                          Locating the Data Items
                                                          The data items used for this purpose are
                                                          carried in the Service Agreement Details

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section of all CDS messages. This can be                    provider and commissioner pair using the
viewed in the NHS Data Dictionary.                          agreement.
CDS DATA GROUP: Activity Type - Service
Agreement Details:
Details of the Service Agreement for the Activity Type
Mandatory/
Optional       Data Item                      Format
                COMMISSIONING SERIAL
M               NUMBER                      an6
NHS Service Agreement Number: A number used to
uniquely identify a NHS SERVICE AGREEMENT by
an ORGANISATION acting as commissioner of
patient care services.
                NHS SERVICE
                AGREEMENT LINE
O               NUMBER                      an10
The NHS SERVICE AGREEMENT LINE NUMBERS
may be used to identify a specific NHS SERVICE
AGREEMENT reference where the main identifier
refers to a general omnibus agreement.
              PROVIDER REFERENCE
O             NUMBER                       an17
A convention agreed locally between a provider
and commissioner for use within a CDS message.

              COMMISSIONER
M             REFERENCE NUMBER                an17
A number (alphanumeric) allocated by the
commissioner to a REFERRAL REQUEST.
               ORGANISATION CODE          an3 or
M              (CODE OF PROVIDER)         an5
The ORGANISATION CODE of the Healthcare
Provider receiving the PbR tariff income.

              ORGANISATION CODE
              (CODE OF                        an3 or
M             COMMISSIONER)                   an5
the ORGANISATION CODE of the original
commissioner to support

Equals Sign Exclusions
The ‘=’ sign convention, used by providers
to exclude activity from PbR, is not affected
by using this locally priced activity
identification method.
Sensitive Data
Use of local codes in the above data items
should not identify sensitive treatments.
Codes that identify the nature of the
sensitive activity (e.g. HIV Clinic) would not
be acceptable. The use of numeric coding
schemes is recommended where the
descriptions are shared locally between the


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Spell Construction                                     Slabs
                                                       The different ‘Slabs’ used by SUS PbR in
Introduction                                           spell construction are as follows:
SUS PbR spell construction uses data                   Slab 0 - Day Case
items submitted on the CDS record and
‘slab logic’ to enable differentiation                 A day case refers to a patient that has been
between patients and identify and                      admitted electively and who does not stay
aggregate related CDS episodes into                    overnight as intended. SUS PbR
Spells. A tariff can then be applied to the            determines a day case based on the
resulting spell.                                       following criteria:

Spells                                                 Patient Classification = 2 (Day Case
                                                       Admission)
A spell is a continuous period of care for a
patient at a given provider.                           Episode Duration = 0 (Discharged on
                                                       same day)
Admitted Patient Care spells can be
constructed from one or multiple episodes.             Admission Type = ELE (elective) derived
                                                       where Admission Method value is one of
Emergency Medicine (EM) (Accident &
                                                       11 (Waiting list), 12 (Booked), or 13
Emergency, A&E) and Outpatient (OP)
                                                       (Planned).
records are also assigned to spells, even
though they are always defined as single               NON (non-elective) or NULL admission
attendances. EM and OP spells therefore                types cannot be classified as day cases,
always consist of a single ‘episode’ of care.          even those with zero LoS.
This is also the case with CDS 160 (Other              Day case episodes are considered as
Delivery Event) activity where a spell                 single episode spells with zero LoS and
always consists of a single episode.                   are therefore not combined with other
                                                       episodes. 1 day case = 1 spell.
A multiple birth delivery, recorded in CDS
160, would still be classified as a single
episode spell.
                                                       Slab 1 - NHS Number (Ordinary
Slab Logic                                             Admission)
A concept known as ‘Slab Logic’ is used to             In an ‘Ordinary’ Admission a patient has a
construct spells based on submitted CDS                non-elective admission or is admitted
data.                                                  electively with the expectation they will stay
                                                       at least one night (even if during their
SUS uses 'slab' logic to match patient                 admission it is decided the patient will not
activity by using the slab-specific data items         stay overnight).
(detailed in the following section) together
with the standard data items used in spell             Slab 1 uses NHS Number to identify the
construction:                                          patient and (in conjunction with the
                                                       standard spell construction data items)
        Provider Code                                 assigns episodes to spells.
        Admission Date
        Discharge Date                                95% of spells use Slab 1 spell construction
        Episode Number                                logic.
        Last Episode In Spell Indicator
The main determinant for assigning
episodes for the same patient into the same
spells is length of stay (LoS).


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SUS PbR Reference Manual v1.3


Slab 2: Provider Spell Number, DoB &                             Episode Number = 1 (provider has
Person Gender Current (Ordinary                                   indicated the record is the first
Admission)                                                        episode in the spell)
In certain circumstances, for instance                           Last Episode in Spell Indicator = 1
where NHS Number is not present or                                (provider has indicated the record
invalid, ‘ordinary’ admission spells can be                       is also the last episode in the
constructed by using a combination of the                         spell)
following data items as a proxy for NHS
Number:                                                          Episode Start Date = Episode End
        Provider Spell Number                                    Date (episode duration = 0)
        Date of Birth
        Person Gender Current                                   Episode Start Date = Spell
                                                                  Admission Date AND Episode End
These data items are used in conjunction                          Date = Spell Discharge Date (spell
with the standard spell construction data                         LoS = 0)
items to construct spells.

                                                          If all the above criteria are met a single
Slab 3: Local Patient Identifier & DoB                    episode spell is created. No additional
                                                          episodes will ever be assigned to this spell
(no longer used)                                          even if further episodes are submitted for
Slab 4: DoB, Person Gender Current,                       the same provider with the same admission
Validated Postcode (no longer used)                       date.
Analysis using 2009/10 data showed that
Slabs 3 and 4 were so rarely used they
were no longer necessary and were                         Slab 7: Regular Admissions
therefore removed from processing.                        A Regular Admission is identified where a
                                                          patient has an elective admission and
                                                          stays less than one day for Regular Day
Slab 5: Confidential Patient                              Admissions or less than two nights for
                                                          Regular Night Admissions.
Records flagged as Confidential Patient in
the CDS record always create a single
episode spell because it is not possible to               A Regular Admission is defined by the
link them to other episodes due to the                    following rules:
removal of identifiable data. Confidential
                                                          Admission Type = ELE (elective) derived
Patient data should therefore be considered
                                                          where Admission Method value is 11
carefully as it may lead to multiple charging
                                                          (Waiting list), 12 (Booked), or 13 (Planned).
for the same ‘spell’.
                                                          And
                                                          (Patient Classification = 3 (Regular Day
Slab 6: Same Day Admissions                               Admission) with an Episode Duration of
As part of Slab 6 logic, SUS PbR applies                  less than 1
the following rules to an incoming episode
                                                          Or
to identify zero LoS episodes that should
create a single-episode spell:                            Patient Classification 4 (regular night
                                                          admission) with an Episode Duration of
      Episode is not flagged as
                                                          less than 2)
       confidential or a day case
                                                          All Regular Admissions form single episode
                                                          spells.

18                            Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
Numbering and Ordering                                   Application of Slabs 0, 7 and 5
Slab numbering identifies the order in which             – Single Episode Spells
the slabs were developed over time in the
                                                         The rules for of Slab 0, 7 and 5 are clearly
iterative releases of SUS. However, SUS
                                                         defined and episodes that fall into these
PbR does not apply spell construction
                                                         categories are easily identified. As
processing in this order. Ordering is
                                                         mentioned above, all result in single
important because a spell will be
                                                         episode spells.
constructed based on the first ‘slab’ for
which the criteria is met. If a record fails to          Application of Slab 6 - Same
meet the required criteria for the first Slab
the next Slab is considered until one is                 Day Admissions
found whose criteria for construction is met             The purpose of Slab 6 is to apply a set of
by the record.                                           rules to episodes with zero LoS and use
The order in which SUS PbR attempts to                   information submitted by the provider on
construct spells using slab logic is as                  the CDS record to determine whether a
follows:                                                 single episode spell should be created or
                                                         whether there is the potential to assign
                                                         other episodes to the spell to create a multi-
                                                         episode spell. Slab 6 logic can therefore
                    Data In                              create single episode spells for (some) zero
                                                         LoS episodes and prevent other episodes
                                                         being incorrectly added to a genuine single
     Slab 0:   Daycase                                   episode spell.
                                                         In each of the following scenarios, the
                                                         episodes relate to a single patient (same
     Slab 7:   Regular Admissions
                                                         NHS Number).


     Slab 5:   Confidential Patient
                                                         Example Scenarios
                                                         Scenario 1: Two episodes submitted for
     Slab 6:   Same Day Admissions                       the same patient and both meet Slab 6
                                                         criteria:
                                                         1st Episode Received:
     Slab 1:   NHS Number                                                 Episode Spell    Episode Episode Episode
               (Ordinary Admission)                       NHS No. Episode Version Version Start     End     Length
                                                               121 E1            1       1 02-Apr 02-Apr           0
                                                                                           Last
                                                          Admi     Disch           Episode Episode
     Slab 2:   Provider Spell, Date of                    Date     Date   LoS      Number in Spell Spell ID
                                                           02-Apr 02-Apr         0       1        1 S100
               Birth and Person Gender
               Current                                   Outcome:Single episode spell created
               (Ordinary Admission)                              using Slab 6.



                Spell Created




19                                    Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
SUS PbR Reference Manual v1.3


2nd Episode Received:                                                                Episode 2 (E2) does not meet
                Episode Spell   Episode Episode Episode
                                                                                     Slab 6 criteria.
NHS No. Episode Version Version Start   End     Length
    121 E1             1      1 02-Apr 02-Apr          0
                                                                                     A new spell (S400) is created
    121 E2             1      1 02-Apr 02-Apr          0                             with the potential for further
                                    Last                                             episodes to be added.
Admi   Disch                Episode Episode
Date   Date    LoS          Number in Spell Spell ID
                                                                      If any of the criteria for Slab 6 are not met,
 02-Apr 02-Apr            0       1        1 S100                     usual spell construction rules apply.
 02-Apr 02-Apr            0       1        1 S200

Outcome:Spell construction for Slab 6
        prevents any further episodes                                 Application of Slabs 1, 2 and
        being assigned to Spell S100.
                                                                      Zero LoS Rules
               However Episode Number = 1                             This section provides example scenarios to
               and Episode Duration = 0 so                            demonstrate how spell construction rules
               meets Slab 6 criteria.                                 are applied to zero LoS spells that do not
               A new spell (S200) is created,                         meet Slab 6 criteria. In each scenario, the
               also with no further episodes to                       episodes relate to the same patient (same
               join.                                                  NHS Number) admitted to the same
                                                                      provider.
                                                                      There are a number of scenarios where
Scenario 2: Two episodes submitted for                                same day admissions result in the
the same patient but only one meets                                   assignment of multi-episode spells. As
Slab 6 criteria:                                                      previously stated, any episode that has met
                                                                      Slab 6 criteria (thus creating a single
                                                                      episode spell) IS NOT subject to the
1st Episode Received:                                                 following rules.
                   Episode Spell    Episode    Episode Episode
NHS No.    Episode Version Version Start       End     Length
                                                                      The following section highlights different
     122   E1             1       1 Last
                                     04-Apr     04-Apr        0       potential scenarios and how incoming
Admi       Disch            Episode Episode                           record data and spell construction rules are
Date       Date    LoS      Number in Spell    Spell ID               used to determine:
 02-Apr     02-Apr        0       1        1   S300
                                                                             In what circumstances the
Outcome:Single episode spell (S300)
                                                                              episodes will be assigned to a
        created using Slab 6.
                                                                              single spell or create separate
2nd Episode Received:                                                         spells
                Episode Spell   Episode Episode Episode
NHS No. Episode Version Version Start   End     Length                       Grouping and Pricing Implications
    122 E1             1      1 04-Apr 04-Apr          0
    122 E2             1      1 04-Apr 05-Apr          1
                                                                             The impact of updates to the spell
                                      Last
                                                                              (additional or resubmitted activity)
Admi    Disch               Episode   Episode
Date    Date   LoS          Number    in Spell Spell ID
 04-Apr 04-Apr            0       1           1 S300                  The following factors affect whether single
 04-Apr 05-Apr            0       2           1 S400                  or multiple spells are created:
Outcome:Spell construction for Slab 6                                        Episode duration and the PbR
        prevents any further episodes                                         Spell LoS derived from Episode
        being assigned to Spell S300.                                         Start and End Dates
               Episode Number  1 and
               Episode Duration = 1 so


20                                        Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
 Episode Number (used to                                     other admissions on the same day
       populate grouper input field                                (Slab 0 logic). Same Day
       Epiorder)                                                   Admissions logic (Slab 6) is not
                                                                   applied to day cases or spells
      Last Episode In Spell Indicator                             constructed using Confidential
       where:                                                      Patient (Slab 5) logic or Regular
          o 1 = Last episode in the                                Admissions logic (Slab 7).
             hospital provider spell
          o 2 = Not the last episode in                       Providing all episodes are APC,
             the hospital provider spell                       CDS Type is not considered
          o 9 = Not known                                      during spell construction.
                                                               Therefore an episode with CDS
                                                               Type 130 (Admitted Patient Care -
      Whether the episodes came in on                         Finished General Episodes) can
       the same or different interchanges                      be assigned to a spell with an
                                                               episode of CDS Type 140
The final point may seem irrelevant with                       (Admitted Patient Care - Finished
regard to spell construction but spell                         Delivery Episodes).
construction logic has no concept of
chronological ordering of episodes. Episode                   An episode with an NHS Number
records are not necessarily submitted to                       can still be assigned to a spell
SUS in the order in which they occurred in                     with an episode where NHS
time and are therefore processed based on                      Number is not present. For
the interchange in which they were                             example, an episode that has no
received. Episodes may be received on the                      NHS Number but satisfies Slab 2
same or a different interchange.                               criteria will create a spell. If
                                                               another episode is received with
Spell construction is therefore effectively                    NHS Number, it will be assigned to
driven by the order of processing. This is                     the same spell (assuming SUS
demonstrated in the following examples.                        PbR finds a match using Slab 2
In the following examples, episode 1 will be                   logic).
considered as the first episode processed
even if it happened later in time.                     Scenario 1a: Single Spell formed from 2
Other considerations when reading this                 zero LoS Episodes
section are as follows:                                1st Episode Received:
      Spell PbR LoS is derived from the                                   Episode Spell    Episode    Episode Episode
       Episode Start and End Dates and                  NHS No.    Episode Version Version Start       End     Length
       does not take any account of                          123   E1             1       1 Last
                                                                                             06-Apr     06-Apr        0
                                                        Admi       Disch            Episode Episode
       Admission and Discharge Dates.                   Date       Date    LoS      Number in Spell    Spell ID
       For example, if a spell is created                06-Apr     06-Apr        0       1        2   S500
       from a single episode where the
       Episode Start and End Dates are                 Outcome:Last Episode In Spell  1 so
       the same, the spell LoS will be ‘0’                     does not meet Slab 6 criteria.
       even if the Hospital Provider Spell                             Single Episode Spell created
       Start and Discharge Dates                                       using Slab 1.
       suggest a spell of longer duration.

      Day Case spells will always create
       a single episode spell, regardless
       of whether the patient had any


21                                  Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
SUS PbR Reference Manual v1.3


2nd Episode Received:                                               2nd Episode Received:
                Episode Spell   Episode Episode Episode                              Episode Spell   Episode Episode Episode
NHS No. Episode Version Version Start   End     Length               NHS No. Episode Version Version Start   End     Length
    123 E1             1      1 06-Apr 06-Apr          0                 124 E1             1      1 08-Apr 08-Apr          0
    123 E2             1      1 06-Apr 06-Apr          0                 124 E2             1      1 08-Apr 08-Apr          0

                                    Last                                                                 Last
Admi   Disch                Episode Episode                          Admi   Disch                Episode Episode
Date   Date    LoS          Number in Spell Spell ID                 Date   Date    LoS          Number in Spell Spell ID
 06-Apr 06-Apr            0       1        2 S500                     08-Apr 08-Apr            0       1        2 S600
 06-Apr 06-Apr            0       2        1 S500                     08-Apr 08-Apr            0       2        1 S700

Outcome:Again episode 2 does not meet
        Slab 6 criteria because Episode
                                                                    Outcome:Again episode 2 does not meet
        Number  1.
                                                                            Slab 6 criteria because Episode
               However, because the NHS                                     Number  1.
               Number, Provider and
                                                                                    However, because the NHS
               Admission Date are the same
                                                                                    Number, Provider and
               SUS will assign these episodes
                                                                                    Admission Date are the same
               to the same spell.
                                                                                    SUS will attempt to assign these
               Where multiple episodes with                                         episodes to the same spell.
               zero LoS are candidates for
                                                                                    Where multiple episodes with
               being assigned to the same spell,
                                                                                    zero LoS are candidates for
               SUS performs a check on
                                                                                    being assigned to the same spell,
               Episode Number.
                                                                                    SUS performs a check on
               Because the Episode Numbers                                          Episode Number.
               are different the two episodes will
                                                                                    Because the Episode Numbers
               be assigned to the same multi-
                                                                                    are the same the two episodes
               episode spell (S500), created
                                                                                    will NOT be assigned to the
               using Slab 1.
                                                                                    same multi-episode spell and
(N.B: See Scenario 3b for an example of                                             instead a separate spell (S500) is
where Episode Numbers are the same).                                                created using Slab 1.
                                                                    Scenario 2: Separate Spells formed from
                                                                    zero and a non-zero LoS Episodes
Scenario 1b: Separate Spells formed
from 2 zero LoS Episodes                                            1st Episode Received:
1st Episode Received:                                                                   Episode Spell    Episode    Episode Episode
                                                                     NHS No.    Episode Version Version Start       End     Length
                   Episode Spell    Episode    Episode Episode            125   E1             1       1 Last
                                                                                                          10-Apr     10-Apr        0
NHS No.    Episode Version Version Start       End     Length        Admi       Disch            Episode Episode
     124   E1             1       1 Last
                                     08-Apr     08-Apr        0      Date       Date    LoS      Number in Spell    Spell ID
Admi       Disch            Episode Episode                           10-Apr     10-Apr        0       1        2   S800
Date       Date    LoS      Number in Spell    Spell ID
 08-Apr     08-Apr        0       1        2   S600                 Outcome:Last Episode In Spell  1 so
                                                                            does not meet Slab 6 criteria.
Outcome:Last Episode In Spell  1 so
        does not meet Slab 6 criteria.                                              Single Episode Spell created
                                                                                    using Slab 1.
               Single Episode Spell created
               using Slab 1.




22                                      Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
2nd Episode Received                                                                   The NHS Number, Provider and
                Episode Spell   Episode Episode Episode
                                                                                       Admission Date are the same
NHS No. Episode Version Version Start   End     Length                                 so SUS will attempt to assign
    125 E1             1      1 10-Apr 10-Apr          0                               these episodes to the same spell.
    125 E2             1      1 10-Apr 12-Apr          2

                                    Last
                                                                                       Where a zero LoS episode is
Admi    Disch               Episode Episode                                            assigned to a non-zero LoS
Date    Date   LoS          Number in Spell Spell ID                                   spell there is no check on
 10-Apr 10-Apr            0       1        2 S800
 10-Apr 12-Apr            0       1        1 S900
                                                                                       Episode Number.

Outcome:Again episode 2 does not meet                                                  Therefore episode 2 will be
        Slab 6.                                                                        assigned to the same spell,
                                                                                       creating a multi-episode spell
               The NHS Number, Provider and                                            (S110).
               Admission Date are the same
               so SUS will attempt to assign
               these episodes to the same spell.                       Scenario 3b: Zero LoS Episode
               However, spell construction rules                       Assigned to an Existing Spell Where
               do not allow a non-zero LoS                             Episodes Have Same Episode Number
               episode to be assigned to an                            1st Episode Received:
               existing spell with zero LoS.                                               Episode Spell    Episode    Episode Episode
                                                                        NHS No.    Episode Version Version Start       End     Length
               Therefore episode 2 will create a
                                                                             127   E1             1       1 Last
                                                                                                             16-Apr     18-Apr        2
               separate spell (S900).                                   Admi       Disch            Episode Episode
                                                                        Date       Date    LoS      Number in Spell    Spell ID
Scenario 3a: Zero LoS Episode                                            16-Apr     18-Apr        2       2        2   S120
Assigned to an Existing Spell Where
Episodes Have Different Episode                                        Outcome:Last Episode In Spell  1 so
Number                                                                         does not meet Slab 6 criteria.
1st Episode Received:                                                                  Single Episode Spell created
                                                                                       using Slab 1.
                   Episode Spell    Episode    Episode Episode
NHS No.    Episode Version Version Start       End     Length          2nd Episode Received
     126   E1             1       1 Last
                                     12-Apr     14-Apr        2
Admi       Disch            Episode Episode
                                                                                        Episode Spell   Episode Episode Episode
Date       Date    LoS      Number in Spell    Spell ID
                                                                        NHS No. Episode Version Version Start   End     Length
 12-Apr     14-Apr        2       1        2   S110
                                                                            127 E1             1      1 16-Apr 18-Apr          2
Outcome:Last Episode In Spell  1 so                                       127 E2             1      1 18-Apr 18-Apr          0

        does not meet Slab 6 criteria.                                                                      Last
                                                                        Admi   Disch                Episode Episode
               Single Episode Spell created                             Date   Date    LoS          Number in Spell Spell ID
                                                                         16-Apr 18-Apr            2       2        2 S120
               using Slab 1.
                                                                         18-Apr 18-Apr            0       2        1 S120
2nd Episode Received
                Episode Spell   Episode Episode Episode
                                                                       Outcome:Again episode 2 does not meet
NHS No. Episode Version Version Start   End     Length                         Slab 6 criteria. If episode 2
    126 E1             1      1 12-Apr 14-Apr          2                       Episode Number = 1 it would
    126 E2             1      1 14-Apr 14-Apr          0
                                                                               have met Slab 6 criteria and
                                    Last                                       been assigned to a single
Admi   Disch                Episode Episode
Date   Date    LoS          Number in Spell Spell ID
                                                                               episode spell.
 12-Apr 14-Apr            2       1        2 S110
 14-Apr 14-Apr            0       2        1 S110
                                                                                       The NHS Number, Provider and
                                                                                       Admission Date are the same
Outcome:Again episode 2 does not meet                                                  so SUS will attempt to assign
        Slab 6 criteria.                                                               these episodes to the same spell.


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SUS PbR Reference Manual v1.3


           Where a zero LoS episode is                      R11. This rule identifies those spells where
           assigned to a non-zero LoS                       days lie within the spell boundaries
           spell there is no check on                       (Admission Date to Discharge Date) but
           Episode Number.                                  outside of the episode boundaries.
           Therefore episode 2 will be                      Any spell containing one or more days that
           assigned to the same spell,                      do not fall within the boundary of an
           creating a multi-episode spell                   episode are considered to contain ‘missing
           (S120).                                          episodes’ and therefore fail this global
                                                            validation rule.
           However, this spell fails the
           grouper check for a unique                       After ordering the episodes by Episode
           Episode Number and therefore                     Start and End Date, SUS PbR applies the
           generates an UZ01Z HRG (Data                     following rules. A spell that fails any of
           Invalid for Grouping).                           these rules is considered to contain
                                                            ‘missing episodes’:
                                                                   Start Date of first episode = Spell
Global Validation Rules                                             Admission Date
Global validation rules are applied on a ‘first
strike’ basis. This means that on failing a                        (For a multi-episode spell), End
global validation rule, further rules will not                      Date of the first episode = Start
be applied and the Spell in PbR / Not in                            Date of the next episode
PbR indicator, output in extracts, will
reflect the first point of failure, regardless as                  (For a multi-episode spell), End
to whether the record would have gone on                            Date of the nth episode = Start
to fail further global validation rules.                            Date of the (n+1) episode
Spell in PbR / Not in PbR indicator is a
derived spell level flag indicating if a spell                     End Date of the last episode =
qualifies for PbR and therefore attracts a                          Spell Discharge Date
tariff. A value of '0' indicates that a spell
qualifies for PbR and therefore attracts a                  Where any of the above are not true, Spell
tariff. All other values indicate that the                  in PbR / Not in PbR (PbR Qualified
activity is excluded from PbR.                              Indicator) is set to 9 (APC Spell with
Overlapping Episodes                                        Missing episodes) and the spell core HRG
                                                            is set to N/A. The spell will not be tariffed.
Any spell which contains episodes that
overlap by more than one day is excluded                    This global validation rule is applied to APC
from SUS PbR processing and the Spell in                    spells only (not OP or EM attendances) with
PbR / Not in PbR (PbR Qualified Indicator)                  the following exceptions:
is set to 8 (APC Spell with Overlapping                            APC ‘open’ spells
Episode(s)). An Episode End Date which
is equal to an Episode Start Date does not
                                                                   APC ‘phantom spells’ (Spell in
constitute an overlap.
                                                                    PbR / Not in PbR indicator = 1)
The episodes are grouped as single
episode spells and the episode HRG is                              CDS 160 (Other Delivery Event)
derived, but the Spell Core HRG is set to
N/A.
                                                            Note: ‘Phantom spells’ are spells where
Missing Episodes                                            the episodes have been logically deleted.
A further global validation rule to account                 Global validation rules are applied on a ‘first
for missing episodes was implemented in                     strike’ basis. The Missing Episodes rule is

24                              Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
applied AFTER the Overlapping Episodes
rule and therefore a spell that has both
overlapping and missing episodes will be
flagged with Spell in PbR / Not in PbR
(PbR Qualified Indicator) 8 (APC Spell with
Overlapping Episode(s) and will not also be
flagged with Spell in PbR / Not in PbR
(PbR Qualified Indicator) 9 (APC Spell with
Missing episodes).




25                                Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
SUS PbR Reference Manual v1.3




26   Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
XML Schema Validation
Validation, Processing and                             Submitted data is validated against
Data Quality                                           standards specified in the NHS Data
                                                       Dictionary. Compliance with these
Introduction                                           standards is required for data to enter SUS.
SUS PbR applies a range of general and                 XML Schema validation failure will cause
PbR-specific validation and processing                 an entire interchange to be rejected. Data
stages to submitted data. Where                        that fails at this stage will not be sent to
submitted activity data is not considered to           SUS.
be of sufficient accuracy or completeness,             Error messages created by the XML
interchanges are rejected. Data quality                translation software show the reasons for
messages are returned to the data sender,              validation failure.
enabling them to resubmit corrected or
completed data.
Applicable Patient Care Settings                       SUS Business Rules
Admitted Patient Care (APC)                            SUS Business Rule validation is performed
CDS 120, 130, 140, 150, 160                            after XML Schema validation and when
Outpatient (OP)                                        data lands at SUS. Individual data items
CDS 020                                                are compared with defined release-specific
Future Outpatients                                     reference data item values to ensure that
CDS 021                                                the submitted data meets the required
Emergency Medicine (EM)                                criteria.
CDS 010                                                SUS Business Rule validation failure also
                                                       results in rejection of the entire interchange.
                                                       In the same way as with an XML schema
Validation                                             failure, the data sender is notified of the
Submitted data is validated to ensure that it          reason(s) for validation failure via an error
conforms to defined standards and can                  message.
therefore be used downstream for reliable
                                                       Certain validation rules may stop
reimbursement and accurate analysis.
                                                       processing of all interchanges for that
Validation ensures that non-compliant
                                                       sender until the error is resolved.
submissions are not allowed into SUS and
are rejected. The sender is notified of why
the data has failed validation.
                                                       SUS Processing
There are three keys stages in validation:
                                                       If an interchange successfully completes
        XML Schema Validation                         business rule checks it will then be
        SUS Business Rules                            accepted into SUS and be added to all
        HRG Validation                                relevant data marts. This does not mean all
                                                       errors within the data have been captured.
Data is validated to ensure that it matches            It simply means that the data is correctly
the defined schema and that the entered                formatted and is of sufficient quality for
values conform to the required formats and             subsequent business processes. Other
meet defined criteria. The values allowed              checks may discover further problems or
for certain data items are defined in                  inadequacies that prevent full processing
reference data and applied within the                  where a desired value cannot be
schema.                                                determined.




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SUS PbR Reference Manual v1.3


HRG Validation                                                        SSC (Specialised Service Code
Derivation of valid HRGs relies on data                                )
items within the submitted patient record.
HRG validation failure may lead to the                   Critical Care
derivation of a UZ01Z HRG (Data not valid                             Critical Care Tariff
for grouping).                                                        Number of days in Critical Care
For more information please refer to the                               (Critical Care period) (for tariff
HRG Grouping section.                                                  and length of stay purposes)

Reasons for failure to group are found at
record level in the online Error extracts                Exclusions
generated alongside main activity extracts if                         Exclusion reason
the option for this supplement is selected at                         Excluded value
the time of extract configuration.

                                                         Tariff
Derivations                                              The appropriate tariff is determined using
Derivations are system-generated data                    the HRG and other activity characteristics.
items that are created by comparing                      These include patient type (day case,
submitted data with applicable                           ordinary elective or ordinary non elective),
corresponding reference data tables and                  Length of Stay, Treatment Function Code
assigning the appropriate derived value.                 (TFC) and Age Group (derived from Age).

There are various types of derivations but in
general most of these derived data items                 Adjustments
support PbR by ensuring accurate
calculation of tariffs and currency.                     Adjustments can be derived from:

Reference data tables, used to derive PbR                             HRG
specific data items, are updated with each                            SSC (Specialised Service
release of SUS to ensure appropriate                                   Code)
coverage.                                                             BPT (Best Practice Tariff
                                                                       Indicator)
                                                                      Organisation Code (e.g.
Types of Derivations                                                   Clinical Commissioning Group
                                                                       (CCG) of responsibility and
The following list shows some examples of
                                                                       CCG of residence)
the types of derivations in SUS:
                                                                      Age
General                                                               Length of Stay (e.g. Excess
                                                                       bed days)
          Spell ID
          Age
                                                         These adjustments can have an impact on
          Length of Stay                                the assignment of the final tariff.

Grouping
                                                         Counts
          HRG (Healthcare Resource
           Group)                                        Counts are similar to derivations but instead
          BPT (Best Practice Tariff)                    of deriving a value with which to populate a
          PBC (Programme Budgeting                      specific data item, a count of instances for a
           Category)                                     particular data item is returned as a value.
                                                         For example Count of Secondary

28                           Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
Diagnosis is a calculation of the total                Dashboard and Tracking tools enable users
recorded number of secondary diagnoses                 to view, monitor and benchmark their data
within the patient care record.                        quality against other providers.
SUS PbR extracts contain a maximum of
12 primary and secondary diagnoses or
procedures. Further ‘repeating groups’ can             Data Quality Flags
be found in the Supplementary extract.                 Possible data quality issues are highlighted
                                                       by assigning a Data Quality (DQ) flag to
                                                       the record. This allows users to clearly
Examples of SUS PbR Counts:                            identify issues and resubmit corrected or
                                                       completed data.
          BPT flags
          SSC days                                    Data Quality flags are assigned to missing
          Length of Stay                              or problematic records. Records with DQ
          Secondary diagnoses                         flags can cause a spell not to be priced by
          Procedures                                  PbR (even though it may still be grouped).
                                                       The PbR Error Extract returns records with
          Investigations
                                                       the corresponding error reason so that
          A & E treatment codes
                                                       senders can correct and resubmit the data.
                                                       SUS PbR validations and derivations are
There is no limit to the number of potentially
                                                       currently documented in the Indicators,
repeating data items being submitted.
                                                       Errors and Data Quality Guide available
Counts enable users to see whether
                                                       on the PbR Guidance page of the HSCIC
further information may be present in the
                                                       website:
Supplementary extract.
                                                       www.hscic.gov.uk/sus/pbrguidance
Counts help increase transparency and in
some cases are also used in validation
such as calculation of Critical Care days.
                                                       Data Cleansing
For more information about the content of              The following examples demonstrate how
extracts please refer to the SUS PbR                   some data quality issues are corrected
Extract Specification                                  through the application of standard pre-
www.hscic.gov.uk/sus/pbrguidance                       defined cleansing processing.
                                                       Diagnosis Codes

Data Quality                                           ICD-10 morphology codes are removed.
                                                       This involves the truncation of incorrectly
Data quality is important in ensuring the              submitted 5 character codes to 4 character
accurate calculation of tariffs and improving          codes.
transparency around why payment may not
have been received for a particular subset             Procedure Codes
of submitted activity. This allows users to            Invalid characters are removed, such as full
identify and understand the reasons for the            stops in OPCS codes.
data quality issues and resubmit revised
data in place of missing or inaccurate data.
SUS PbR performs a number of data                      Critical Care
quality checks. Data cleansing processes               Critical Care data quality checks ensure
are limited to formatting clinical codes such          that Episode End Date aligns with the
that they will be accepted by the grouper. It          expected Critical Care treatment end date.
is important to note that no other CDS items
are changed by SUS processes.

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SUS PbR Reference Manual v1.3


HRG Grouping                                               interchanges and view Data Quality
Checks and exclusions are made based on:                   Reports (DQR) of the data within.
                                                           Tracker Reports
          ‘Illogical data’ such as a day
           case that covers three days,                    For convenience, Tracker information is
           invalid treatment function                      also provided in snapshot workbook format
           codes or diagnosis/procedure                    on the SUS website under Weekly Trust
           codes which are classified as                   Statements on the Operational Support
           other or unspecified                            pages
                                                           www.hscic.gov.uk/sus/operationalsupport
          Data issues and missing data
                                                           These weekly reports track the status of all
                                                           data submissions up to the date displayed
Rather than rejecting data, it is either                   in the report heading. They allow the status
‘cleansed’ or ‘flagged’ as containing issues.              of all submissions for a particular
It then continues through the process and                  organisation to be checked. Senders are
can lead to the derivation of a UZ01Z HRG                  encouraged to use the Tracker reports to
(Data invalid for grouping) and assignment                 check that data has been successfully
of a zero price.                                           received by SUS. This is particularly useful
                                                           after any organisational or system (PAS or
                                                           XML) changes have been made.
SUS Data Quality Dashboards
                                                           Monthly Database Counts
A number of dashboards have been
developed by the HSCIC to support users in                 Reports are generated and published on a
monitoring and driving improvements in the                 monthly basis to track the number of
quality and completeness of SUS data.                      records submitted to SUS (by activity
The dashboards report on the coverage and                  month) for the last 18 months. Activity is
quality of the APC, Outpatient and A&E CDS                 displayed for each CDS type on a separate
types, as well as focussing on other key                   worksheet and can be used to highlight
areas for improvement of data quality such as              where an organisation has peaks and
Maternity and Critical Care.                               troughs in activity submissions, has
                                                           duplicated or deleted data or where an
There is no limit to the number of users within
                                                           organisation has started or stopped
an organisation that can register for access to
                                                           submitting data.
the SUS dashboards. More information about
how to register can be found under the ‘How                www.hscic.gov.uk/sus/operationalsupport
do I analyse data quality?’ on the SUS
Guidance web page:
www.hscic.gov.uk/susguidance


Tracker
The status of a CDS interchange
submission can be monitored using the
SUS ‘Tracker’.
Tracker can be accessed via the SUS
Portal by selecting Service Tracking
Reports. It shows the live status of
interchanges submitted to SUS and
whether they have been processed and
made available in the SEM and PbR marts.
Users can drill down into these

30                             Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
HRG Grouping                                            Grouper Processing
                                                        A number of validation and pre-processing
Introduction                                            stages take place before the actual
                                                        grouping takes place whereby HRG codes
HRGs                                                    are assigned to patient record data.
Healthcare Resource Groups (HRGs) are
the ‘currency’ of PbR for Admitted Patient              After grouping, Best Practice Tariff (BPT),
Care, Outpatient procedures and A&E                     Specialised Service Code (SSC) and
attendances. In the context of PbR                      Programme Budgeting Category (PBC)
‘currency’ refers to the units of healthcare            flags are assigned.
for which a payment is made.                            Simplified Grouping Diagram
HRGs are clinically meaningful groupings of
patient activity derived from NHS patient                                     Input Data
records, primarily using procedure and                         Patient Activity (Episode &/or Spell Data)
diagnosis codes. They support PbR by
providing a means of determining fair and
equitable reimbursement for healthcare
                                                                               Validation
services by providing consistent 'units of
currency', based on expected resource use.
HRG Design                                                           Radiology Pre-processing
HRG design is developed and maintained
by the HSCIC National Casemix Office,
driven by policy and assured nationally                                   Pre-processing
through Expert Working Group consultation.                                   (Combinations)
The design for each version of the
classification is represented by a definitive
set of rules and reference data. It is                             Unbundled Activity
implemented by an algorithm, delivered via
a software application, which follows design
rules to interrogate reference tables to
determine whether criteria for candidate                                   Grouping:
HRGs are met by the incoming patient
record data. Using a process of                                             Multiple Trauma
elimination, the most appropriate HRG is                                    Procedure driven
determined and assigned to the activity.
                                                                   Global Exception (e.g: PPNCD)
The Casemix ‘Local’ Grouper                                                      Diagnosis
The Casemix Local Grouper is the software
application that aggregates patient level                        Assign Flags (BPT, SSC, PBC)
coding information into HRGs.
The local grouper performs validation
checks before using a complex algorithm to
assign HRGs to patient records and                                          Output Data
produces output files which contain the                           Patient Activity with Assigned
original input data along with the assigned                             HRGs and Flags
HRGs. It also produces quality files that
contain details of any errors or conflicts.



31                                   Copyright © 2014, Health and Social Care Information Centre. All rights reserved.
SUS PbR Reference Manual v1.3


Validation                                                  Grouping
Validation checks are built into the local                  Grouping is the main stage of the process
payment grouper and are applied prior to                    in which one HRG code is assigned to the
the HRG code being assigned to a patient                    Spell. This is referred to as the core HRG.
record. This checks the OPCS codes to                       Patient record data items, such as
ensure they are valid. Reasons why a code                   procedures, diagnoses, age and length of
may not be seen as valid includes:                          stay are used to determine the appropriate
                                                            HRG code for the Spell.
        Logical inconsistency (e.g. paediatric
         procedure being given to someone                   Assign Flags (BPT, SSC, PBC)
         over 18 years old)                                 Best Practice Tariff (BPT)
        An invalid or missing code has been                Most Best Practice Tariff flags are
         assigned e.g. a Treatment Function                 generated by OPCS and ICD10 codes,
         Code that does not exist or clinically             These may be required in combination and
         irrelevant for grouping e.g. family                may also require qualification by other
         history of diabetes.                               codes, for example site or approach codes.
        If a deliberately ambiguous OPCS
         code is used (e.g.                                 Only certain HRGs can be flagged as best
         diagnosis/procedure ‘unspecified’)                 practice. In addition age criteria and type of
                                                            admission will determine whether activity
Radiology Pre-processing                                    can be flagged as best practice.
Pre-processing occurs for radiology                         Specialised Service Codes (SSC)
activity because it must be mapped to
reference data before processing.                           SSCs are assigned based on the record
                                                            meeting predefined reference criteria.
Pre-processing:
                                                            Programme Budgeting Categories (PBC)
Pre-processing involves creation of
combination procedure codes, and logical                    The grouper maps the Primary Diagnosis of
deletes.                                                    a patient record to a Programme Budgeting
                                                            Category (PBC) which is then output by the
Unbundled Activity:                                         grouper. There is no direct mapping of
Unbundled procedures are processed                          HRGs to PBCs. The programme budget
separately to derive unbundled HRGs (See                    category allows high level reporting on the
Unbundled HRGs). The grouper then                           amount of money being spent on specific
ignores these unbundled components when                     treatments, such as cancer or heart
deriving the core HRG.                                      disease.
When all significant procedures in an
admitted patient care episode or spell are
unbundled, diagnosis is used to derive a                    Unbundled HRGs
core HRG for the episode. For outpatient                    A pathway of care typically consists of a
care, if all procedures are unbundled the                   number of different service elements such
episode is allocated one of the eight                       as diagnostic imaging, high cost drugs
relevant non-admitted care attendance                       and rehabilitation. Unbundled HRGs
HRGs as a core HRG.                                         account for these consumable elements,
There can be one or more ‘unbundled’ HRG                    allowing them to be commissioned, priced
codes assigned that can be used to identify                 and paid for on an individual basis. PbR
the use of repeating resource use such as                   data contains the first 12 unbundled HRG
scans.                                                      codes generated for the activity.



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